AAP Voices Blog

Lessons COVID Pandemic Taught on Avoiding Overuse of Antibiotics

We all surely aspire to be that “guru” clinician who needs nothing more than a good history and a detailed physical exam to make the right diagnosis, whether it be for an uncomplicated respiratory tract infection or a complex patient with unexplained symptoms.

It can be tempting to vent about how some clinicians may overuse technology, including diagnostic tests, as a crutch for clinical diagnosis. You know, when people say things like “Back when I was a trainee, we didn’t have all those expensive blood or imaging tests and we actually examined our patients.”

There’s probably some truth in there. But at the same time, for many good reasons, we all rely immensely on a variety of diagnostic tools, many of which have revolutionized our ability to make timely and accurate diagnoses.

Some recent experiences during the COVID-19 pandemic emphasized how crucial diagnostic testing can be for antibiotic stewardship.

The first is obviously testing for COVID-19 itself. Some reports have indicated that rates of antibiotic prescribing increased during the pandemic, including for patients diagnosed with COVID. However, in one recent report, the onset of the pandemic was associated with a sustained reduction in antibiotic prescribing for respiratory conditions, including extremely low rates for patients with COVID.

“Overuse of antibiotics for patients diagnosed with influenza remains a long-standing problem, but recent experience with COVID suggests that this practice may be amenable to change.”

One of the best explanations for this observation is that clinicians quickly gained an understanding of the clinical and epidemiologic features associated with this viral infection, aided in part by the use of diagnostic tests and followed guidance to avoid antibiotics. Overuse of antibiotics for patients diagnosed with influenza remains a long-standing problem, but recent experience with COVID suggests that this practice may be amenable to change.

Another example from the pandemic helped to remind us of the value of rapid point of care testing for group A Streptococcus (GAS). In order to preserve our supply of personal protective equipment, in the early part of the pandemic, the Intermountain Healthcare system temporarily limited the availability of GAS testing and instead advised clinicians to use clinical judgment for diagnosis and treatment decisions.

While this was likely a reasonable decision in the midst of an evolving crisis, it was not without consequences. Whereas before the pandemic started, more than 90% of patients treated for GAS were tested, this declined to below 40% during the period when testing was limited. As a result, the percentage of patients with pharyngitis treated with antibiotics increased by more than 20%. Undoubtedly this included many patients offered antibiotic treatment who would have otherwise tested negative.

Ultimately, previous testing practices were restored and prescribing rates returned to normal levels. This experience served as a potent reminder for many of us of just how valuable it is to have a low-cost, rapid and highly sensitive test for GAS available.

What can we hope for and expect with regards to the role of rapid testing for respiratory pathogens and antibiotic prescribing?

Although clinical guidelines provide sound advice for diagnosing suspected bacterial causes of a variety of conditions like otitis media, sinusitis and pharyngitis, the ability to accurately distinguish between viral and bacterial causes remains extremely challenging without microbiologic confirmation. Furthermore, the rates of inappropriate prescribing in the U.S. remain too high. While the solutions to this problem are undoubtedly multifactorial, these recent examples illustrate the power of rapid diagnostics to aid in ensuring appropriate antibiotic prescribing.

We must support further scientific advancement for novel rapid diagnostics as well as support work to gain a better understanding of how to best implement tests as part of strategies that add value for clinicians and patients during routine clinical care. These tools can help improve care for our patients and help fight antimicrobial resistance.

Resources:

• Ha D, Ong'uti S, Chang A, et al. Sustained Reduction in Urgent Care Antibiotic Prescribing During the Coronavirus Disease 2019 Pandemic: An Academic Medical Center's Experience.
• Seibert, A, Stenehjem, E, Wallin, A, et al. (2022). Rapid streptococcal pharyngitis testing and antibiotic prescribing before during the COVID-19 pandemic.